Nursing Diagnosis: Ineffective Airway Clearance Possible Etiologies: (Related to)

Goals/ Objectives: Short term goal: Client will demonstrate signs of patent airway and adequate oxygen

Nursing Actions 1. Assess respiratory status every hour during acute phase: lung sounds, respiratory rate and depth, presence and severity of wheezing, breathing pattern, use of accessory muscles. 2. Assist patient to assume

Rationale Outcome Criteria: 1. Some degree in bronchospasm is present with obstruction in airway and may be manifested with wheezing or absent breath sounds in severeasthma. Tachypnea is usually present to some degree and respiratory dysfunction is variable depending on underlying process such as allergic reaction. 2. Elevation of head of the bed facilitates respiratory function by use of gravity, however client in distress may seek position that most eases breathing. 3. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. 4. Provides some means to cope with or control dyspnea and reduce air trapping. 5. Hydration helps thin secretions, facilitating expectoration and using warm liquids may decrease bronchospasm. Client will be able to identify and avoid potential allergens or stimuli that would triggerasthmaattack and be able to handle symptoms if recurrence comes, prompt follow up check up and to always bring or have the prescribed medication/s on hand in Client will verbalize reduction or absence in difficulty in breathing and feeling of chest constriction, respiration and cardiac rate within normal range, absence or reduction of inspiratory and expiratory wheezing, and ability to resume to activities.

Bronchospasm Increased production of secretions; retained secretions; thick, viscous secretions

exchange within 3 days.

Decreased energy/ fatigue

Long term goal: Client will demonstrate behaviours to improve or maintain airway clearance and identify potential complications and initiate appropriate actions.

to comfortable position, i.e. elevate head of bed, have client lean on overbed table or sit on the edge of bed. 3. Keep environmental pollution to a minimum according to individual situation. 4. Encourage and assist abdominal and pursed lipbreathing exercises. 5. Increase fluid intake to 3000ml/ day within cardiac tolerance. 6. Provide warm liquids and

Defining characteristics: (Evidenced by)

Statement of difficulty in breathing Feeling of chest constriction Changes in depth/ rate of respiration; tachypnea

Tachycardia Use of accessory muscles or marked respiratory effort

Abnormal breath sound, inspiratory and expiratory wheezing

recommend intake of fluids between meals, instead of during meals. 7. Administer medications as indicated. 8. Monitor side effects of bronchodilator (tremors/ tachycardia). 9. Provide supplemental humidification, e.g., neutralizer in respiratory treatments. 10. Monitor ABGs, pulse oximetry, chest x- ray.

6. Fluids during meals can increase gastric distension and pressure on the diaphragm. 7. Anticholinergic medications are the first line drugs for clients with this condition. 8. Humidity helps reduce viscosity of secretions, facilitating expectoration and may. 9. Breathing exercises help enhance diffusion,nebulizermedications can reduce bronchospasm and stimulate expectoration. 10. Establishes baseline for monitoring progression/ regression of disease process.

caseasthmaoccurs.

Cough (persistent), without sputum production

Prolonged expiration

Cardiovascular Nursing Management

Controlling cholesterol levels Oxygen therapy Encouraging mobility and independence or passive exercises as appropriate Tackling the factors that increase the risk of heart disease, such as smoking, poor diet and little physical exercise if appropriate Record duration of pain, amount of medication required to relieve ir, and accompanying symptoms. Cardiovascular Disease Pathophysiology

Ask the patient to grade the sverity of his pain on a scale 1 to 10. Monitor the patient for chest pain, hypotension, coronary artery spasm, and bleeding from the catheter site. Explain the cardiac catheterization to the patient. If the patient is scheduled for surgery, explain the procedure and events. Help the patient more effectively cope with stress and identify activities that precipitate pain. Stress the need to follow the prescribed drug regimen. Encourage the patient to maintain the prescribed diet. Encourage regular, moderate exercise.

BRONCHIAL ASTHMA IN ACUTE EXACERBATION PATHOPHYSIOLOGY

Predisposing Factors Gender, Age, Family History, Race (animal dander, dust, pollen, etc.)

Precipitating Factors Viral Respiratory Infections, Allergen Exposure Change in Weather, Smoking, Exercise

Exposure to different pathogens

Entry of the allergen

Release of immunoglobulin E (IgE)

Release of different chemical mediators

Mast cell degranulation

Release of the different inflammatory chemical mediators

Leukotrienes inflammatory mediators

Prostaglandins

Histamine, bradykinin, & other

Release of eosinophils (to combat allergen)

Opening of the mucosal inrtracellular junction

Inflammatory process

Mucus production vagal efferents

Increase vascular permeability

Direct stimulation of the

Mucosal edema

Bronchoconstriction

More release of other inflammatory mediators

Decrease ciliary function

Epithelial damage

Further edema

Mucus hypersecretion

Increased airway responsiveness

Wheezing, continuous coughing, feelings of chest tightness

dypnea, moist skin, tachypnea

fatigue, anxiety

View more pathophysiology and schematic diagrams at Nurseslabs.com